The Florida Agency for Health Care Administration (AHCA) “determined that the facility failed to ensure a safe environment for 40 of the 60 patients” in two of its three patient units. While conducting a tour of the facility, AHCA surveyors found sharp objects in patient areas. These included a chipped plexiglass window covering in the day room, broken laundry hampers in patient rooms, and a cracked plexiglass media cabinet covering, all of which had sharp exposed edges.
Separately, AHCA surveyors also found that the facility “failed to ensure sufficient staff coverage to ensure appropriate supervision” of four patients. Close observation of patients was not maintained, even though these patients were ordered by their physicians to be under one-on-one supervision or 15-minute checks. In one case, a patient engaged in self-harming behavior while she was supposed to be under close observation. An AHCA interview with a mental health technician at the facility further revealed that “her assignments often result in her being responsible for patients on rooms not close to each other which made completing the 15 minute checks difficult.”